Telemedicine: Treating Physical Problems Through Virtual Means

The use of telemedicine has been expanded to include a large portion of patient visits in order to respect the physical barriers instated by government and state officials such that the risk of COVID-19 transmission be minimized. ^, Specifically, the barriers associated with the provision of virtual musculoskeletal care have been removed in the wake of the COVID-19 global pandemic. Insurers now reimburse for telemedicine and legislature, which allows the provision of virtual care, even going as far as to allow the practice of telemedicine across state lines for some encounters in some jurisdictions. A health care industry analysis by Bestsenny and colleagues suggested that in health care there had been a rapid adoption of telemedicine with high rates of both patient and provider satisfaction.

There are many benefits and challenges for sports medicine surgeons in engaging in virtual visits with patients. Major limitations to the use of telemedicine include technical difficulties resulting in lag or premature ending or disruption of a visit, concern for the quality of the encounter, and inability to perform a complete physical examination. These limitations may negatively influence the diagnostic value of a new or return patient encounter. However, there are significant benefits to these visits, including decreased risk of COVID-19 transmission, saved travel time for patients, and potentially lower rates of no-shows. A recent article by Tenforde and colleagues sought to describe the results from a quality improvement initiative during a rapid adoptive phase of telemedicine for outpatient sports and musculoskeletal physicians where surveys were completed by 119 patients and 14 physiatrists. The investigators reported that telemedicine was primarily used for follow-up visits (70.6% of visits); patients rated their experience as excellent or very good between 91.6% and 95.0% of the time with regard to having concerns addressed, communication, treatment plan development, convenience, and satisfaction; the rate of no-show was only 2.7%; and the key barrier identified for the visits was technical issues.

Although telemedicine continues to expand and the efficiency and technical quality of visits will likely to continue to improve, the in-person physical examination is impossible to replicate, because this is a skill that is cultured and developed throughout training. Tanaka and colleagues recently proposed a set of checklist items and systematic virtual examination techniques to help address these limitations. Their recommendations for a virtual checklist include (1) ensuring the camera is secured in a steady position; (2) numerous space and positioning guidelines for the knee, hip, shoulder, and elbow depending on the extremity that is the chief complaint; (3) lighting recommendations; (4) clothing recommendations depending on the extremity that is the chief complaint; and (5) ensuring that the location allows the patient to speak privately. For the systematic virtual examination, the investigators propose various maneuvers that patients can perform in conjunction with provider instruction in the comfort of their own homes, and provide approximate weights of household items that can be used during provocative strength tests. Because telemedicine is likely to remain common in the examination and evaluation of patients presenting for sports medicine evaluations, development of further examination maneuvers and new technology that will allow improved examinations will be imperative. Future directions may include standardized video instructions for patients, application of motion capture technology, and more reliance on diagnostic aids. Sports medicine surgeons will need to adapt their diagnostic algorithm in the virtual era in order to continue to provide the highest quality of care for their patients.

Financial Implications

High-volume orthopedic sports medicine centers have been forced to quickly absorb significant revenue losses that could not have been anticipated. Because these institutions were unprepared for such rapid financial losses, many are on the verge of bankruptcy and, for most, a large source of income (elective surgery) has been suddenly and dramatically curtailed. ^, As a result of financial pressures, many institutions have instituted pay decreases, furlough policies, and even orthopedic staff downsizing. In order to respond to these financial pressures and better align themselves with their institutional plight, hospital-employed surgeons may find themselves accepting pay decreases, and private-practice surgeons may seek out governmental loans to weather the financial storm. The elimination of elective surgery and by proxy income for sports medicine surgeons may have forced some to seek out alternative sources of income, including increased call and locum positions. As sports medicine surgeons return to a new normal, there is likely to be immense pressure to recoup the missed volume. However, the reality is that financial losses in the current fiscal year will have to be amortized in upcoming years and may have implications for surgeon decision making and workload.

The likely ripple effects of the current financial difficulties associated with COVID-19 are that financial disaster planning will become a part of institutional contingency planning. Specifically, institutions will pay increased attention to their cash flow, cash reserve, and maintaining a health account receivable. In addition, surgeons have become sensitized to the importance of having cash on hand to cover ongoing monthly expenditures in the absence of monthly income. Financial wisdom suggests 6 months of typical salary as appropriate liquidity.

Psychosocial Perspectives: Effects of Off-Service Deployment

With governmental and institutional focus on resuming patient care and returning to a new normal, the short-term and long-term effects of being immersed in a critical care environment may be overlooked. Many physicians were previously required to care for patients with COVID-19 or volunteered to do so, which has been shown to be a significant stressor and to impose a large psychological burden. ^, A recent worldwide study of the impact of COVID-19 on spine surgeons revealed that family health concerns and anxiety were common and significant stressors, and that loss of income, clinical practice, and extent of surgical management varied widely. It is plausible, and likely, that these trends exist for sports medicine surgeons as well. Because COVID-19 disproportionality affects individuals of an older age, older sports medicine surgeons may be at risk of increased susceptibility and this too may have a psychological impact. Because sports medicine surgeons are required to be in hospital settings, this anxiety may be unavoidable and frequent. Such studies highlight the challenges experienced by orthopedic providers and the need for guidelines to be established for (1) psychosocial treatment of these providers, and (2) for anticipation of a second COVID-19 wave.

Research Productivity and Expectations

There has been a profound increase in research productivity during recent months, which coincides with diminishing clinical responsibilities. Furthermore, there is likely an academic “gold rush” to take advantage of the high rate of acceptance for articles pertaining to the COVID-19 pandemic. Gazendam and colleagues recently described this phenomenon as the infodemic of journal publication. This group performed a systematic literature search and found that, over the 13-week period since the initial documentation of COVID-19, a total of 1741 articles pertaining to COVID-19 and severe acute respiratory syndrome–coronavirus-2 (SARS-CoV-2) were published in scientific journals, representing an exponential increase in academic productivity. This group also noted a short time from submission to publication, and a higher proportion of commentaries and opinion articles in journals with high impact factors.

Although a similar exploratory study has yet to be performed specifically for orthopedic research, similar trends are likely present. This trend would have benefits but also potentially negative consequences, if increased academic output is a function of sacrifices in quality. However, benefits of this trend include both personal and institutional gains in academic productivity and the potential to advance the field at a much more rapid pace. Institutions may seek to institute research infrastructures that give them the propensity to maintain the productivity observed during this era both now and in future years.

Anxiety, Pain, or Safety: Which Should Be Prioritized?

Patients have expressed significant concerns in coming into a hospital setting, whether this is for clinical evaluation or a surgical procedure. Although hospitals are prioritizing minimization of the risk of COVID-19 transmission, for patients not routinely part of hospital settings, this can be an overwhelming and anxiety-provoking experience. In contrast, social isolation has been shown to be associated with increased anxiety and stress, and the additional effects of musculoskeletal injuries in combination with this remains unknown. Because the balance of patient care, financial incentives, and COVID-19 risk is delicate, it will be imperative to appropriately counsel patients regarding this anxiety. The authors recommend taking advantage of clinical encounters in the telemedicine setting to prime patients to their experience in the hospital and to emphasize the precautions set in place to minimize the risk of COVID-19 transmission and the need to abide by these regulations. This approach may address anxiety through guiding expectations, addressing pain through conservative or surgical care in the inpatient setting, and ensuring the safety of all in these settings.

Returning to Sport, Eventually

Because amateur sporting events have been classified as low-priority events in the sequence of returning to a new normal, it is uncertain as to when, and the extent to which, sports will resume. Because athletes represent a large proportion of patients evaluated and treated by sports medicine surgeons, and because athletes remain sidelined, this has implications for both patients and providers.

There remain many questions for athletes. These questions include, (1) whether athletes who have contracted COVID-19 will experience long-term effects that influence their health and subsequently their game performance (and if so, what those long-term diseases and consequences are); (2) for those unaffected but that remain sidelined, how potential deconditioning or delayed treatment of a musculoskeletal injury will influence their propensity for return to sport and their performance; and (3) what the future of organized sports will look like. At the time of this writing, some professional sports, such as golf and mixed martial arts, have experienced some success in reinstating regular events because a surge of COVID-19 cases has not been observed (this may be a function of these sports being individual based). Hockey and basketball are sports with smaller teams, which may make this effort slightly less challenging than sports with large teams, especially because these sports were in the postseason. In order to facilitate a safe return to sport, some of these larger team sports organizations have explored the so-called bubble concept; however, professional baseball has experienced early setbacks, and other large spectator sports such as football may also if COVID-19 transmission cannot be adequately controlled. These complications indicate how difficult it will be for amateur sports, including high school and collegiate athletics, to resume regular schedules before the introduction of a widely available vaccine. It is hoped that future protocols can improve safety for these professional athletes and the staff that surround them.

It will be imperative for sports medicine surgeons to safely guide athletes to returning to sport, regardless of when that is or what it looks like. It will be essential for sports medicine surgeons and those involved in the care of athletes to counsel athletes to safely return to sport. In this way, clinicians may help their athletes to avoid injuries associated with returning to sport, such as ruptures of the Achilles tendon or anterior cruciate ligament. Close attention must be paid to fatigue and signs of imminent injury, such as pain with activity, and the athletes must be guided accordingly. Although clinicians are passionate about the return of sports and hope that athletes can soon return to doing what they love, their number 1 priority must be to facilitate a safe return.

The Impact of COVID-19 on Rehabilitation and Home Injury

Another unique cohort of patients being affected by the COVID-19 pandemic are those who underwent a surgical procedure in the period before the pandemic. These patients who required extensive rehabilitation and physical therapy were unable to receive it in most cases. Prohibiting this essential aspect of surgical recovery may predispose such patients to suboptimal outcomes compared with their counterparts who were able to successfully complete physical therapy and rehabilitation. It is also likely that such patients will endure a longer recovery than their counterparts accordingly. Sports medicine surgeons and physical therapists will need to be conscientious of this impact and help these patients experience the best clinical and functional outcomes possible.

As many individuals continue to seek ways of maintaining fitness and staying healthy during the pandemic, a trend in injuries related to home exercise programs may be observed. These patients may develop overuse tendinopathies of the biceps and rotator cuffs if they are not accustomed to performing these exercises regularly. As such, sports medicine surgeons are likely to continue to observe an increase in these types of injuries as long as gyms and fitness centers remain closed.